Safety-related adverse events after major surgical operations are a major contributor to the incidence of morbidity and mortality for patients. In the National Surgical Quality Improvement Program (NSQIP), a risk-adjusted adverse event reporting system for major surgical operations in the Department of Veterans Affairs, the rates of adverse events (30-day post-operative morbidity and mortality) have been compared annually since 1994. All the surgical programs have been ranked anonymously by the ratio of observed to expected (O/E) adverse events. The information derived is provided to each hospital annually, and each year's performance is compared to the last. Post- operative surgical morbidity and mortality have declined 43% and 28%, respectively, since the initiation of the program. The aim of this demonstration project is to achieve similar improvements in adverse event rates after major operations in a sample of nonfederal hospitals by applying the methodology of NSQIP. The hypothesis, that NSQIP methods can be successfully integrated into nonfederal hospitals and that feedback of comparative risk-adjusted adverse event data will produce improvement in the rates of post- operative adverse events in these hospitals, will be tested in 10 Selected institutions. The interventions that will be tested are: (1) ongoing feedback of performance data in the form of comparative rates of adverse events (O/E ratios); (2) structured site visits to low and high outlier institutions focusing on the systems issues, latent process failures, and processes and structures that promote patient safety and reduce preventable adverse events; (3) identification of safe systems and human factors issues that contribute to the reduction of preventable adverse events found in institutions with consistently low adverse event rates and dissemination of this information to institutions that have consistently high rates of adverse events; and (4) analysis of cases of low-risk patients who experience an unexpected adverse event to detect latent errors in patient safety systems in surgery. A business plan for expanding NSQIP to additional nonfederal hospitals with a self-sustaining funding base derived from participant fees will be implemented if the initial program is successful.